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Population Care Delivery (PCD) is a new healthcare delivery model taking shape at innovative healthcare organizations. PCD evolved as a response to the ineffectiveness of traditional primary and specialty care delivery models in meeting organizational commitments under Value-Based, Accountable Care, and Risk-Sharing (VBARS) Agreements. In a VBARS environment, healthcare organizations have accountability for population-level clinical and financial outcomes in addition to the patient-level responsibility that they have always had.

Traditional primary and specialty care delivery models relied on individual provider/patient interaction and patient-level clinical decision-making tailored to personal preferences and based on a variety of different health and behavioral variables. Treatment and communication tools and workflows were optimized for achieving health and wellness goals for individuals. For the most part, individual patients had to initiate interactions with the healthcare system to address their healthcare needs. The services they received and the clinical and financial outcomes they experienced greatly varied based on the specific provider they selected even within the same healthcare organization!

Under VBARS Agreements, healthcare organizations are financially and reputationally motivated to manage population-level outcomes. They are also motivated to deliver those services with a high degree of consistency and efficiency. Individual-oriented tools are not optimized for population-level interventions and are occasionally outright hurdles. So PCD tools have been created to meet the need. The majority of PCD tools rely on information and communication technologies, and leverage advanced analytics and increasingly artificial intelligence and machine learning to accomplish their tasks.

An active Population Care Delivery Platform (PCDP) must perform the following functions:

1. Population Analytics                                                         

2. Intervention Design:

• User Engagement
• User Experience
• Behavioral Change
• Intervention Type

3. Healthcare System Integration

• Provider Engagement
• Electronic Medical Record Integration

Population Analytics

Population analytics is the fuel that powers an effective PCDP. Three main categories of analytics are necessary to drive an effective PCDP: User Analytics, Measure Analytics, and Effectiveness Analytics.

User Analytics focuses on segmenting the population into personas (or profiles) with similar healthcare needs and behavioral characteristics. The personas drive the creation of interventions that meet the healthcare needs of this group of users and inform the selection of communication channels and behavioral incentives to motivate any necessary user actions. Predictive user analytics is a subcategory that focuses on anticipating future needs and utilization of healthcare services.

Measure Analytics focuses on the organizational performance on a large number of clinical and financial measures tied to the organization’s strategic goals and initiatives. Evaluating year-over-year performance and benchmarking organization performance to regional and national production, measure analytics provides the intelligence necessary for setting performance targets and allocating resources.

Effectiveness Analytics calculates the impact of various interventions on measure performance. It helps guide resource planning and directly invest in different tools and programs to achieve the targeted improvements. Another important use of effectiveness analytics is calculating return on investment (ROI) when specific measures carry revenue implications through shared savings or performance bonuses. This helps motivate continued organizational support of PCDP investments.

Intervention Design

The PCDP tool set of interventions includes virtual care delivery (our team uses the MDLive CareLink) and population care delivery teams which deliver one-to-many healthcare services compared to the one-to-one traditional approach. An example of one-to-many delivery is our FIT colorectal cancer screening program where a team of one NP and four support staff orders FIT kits for over 30,000 users, screening over 5,000 every year. This program achieved an over 10% improvement in population colorectal cancer screening rates and moved the organization into the 90th percentile performance nationally, up from the 50th percentile in three years.

To effectively deploy these interventions to improving population-level performance, the PCD leadership team employs a variety of user engagement tools to increase user participation in the various interventions. These engagement tools include interactive voice response calls (IVR), email, mobile applications, texting, and phone calls. The user analytics profiles mentioned above help optimize the selection of engagement tool for individual members. Customer relationship management (CRM) tools, also help keep track of personal preferences and of those who decide to opt-out of PCD interventions.

User experience design and design thinking methodologies are used to create coordinate the various touchpoint with users. Behavioral change techniques, including multiple incentives, are also integrated into the different interventions and evaluated using effectiveness analytics to maximize engagement, participation, and performance improvement.

Healthcare System Integration

Despite the deficiencies of primary and specialty care that led to the need for PCD, they remain hugely crucial for meeting many healthcare needs for society. If PCD is to continue to grow and contribute the improving clinical and financial outcomes of healthcare, it will need to integrate with the current healthcare system. Provider engagement and education regarding the benefits of PCDP and gaining their support and endorsement of PCD interventions to their patients is critically important to PCDP’s success. Finally, integrating PCD teams and information into electronic medical records (EMR) will help alleviate the fragmentation of care and will provide multiple opportunities to gain provider engagement and support further.